Citation

Abstract

The management of patients with open abdomens is an evolving concept. Certain
techniques for managing the open abdomen patients can be effective in treating ACS. The
goal of therapy is to maximize tissue perfusion and minimize potential intra abdominal
complications, such as fistulas and hernias. Meticulous care of the bowel, minimizing
trauma from techniques or systems used to cover abdominal contents and protection of
the bowel from exposure to the environment can reduce the complications associated
with the open abdomen. A Temporal Abdominal Closure should not only protect the intra
abdominal contents, but facilitate primary closure of the fascia and minimize the need
for secondary repairs of ventral hernias and subsequent repair. Serial bladder pressure
monitoring should be a part of post-operative management protocols in high-risk patients
and decompression of the abdomen with a pressure of > 25-30 mmHg should be considered
even without clear clinical evidence of ACS. While many closure techniques are reported
in the literature, a dynamic closure technique, such as Vacuum pack appears to have an
advantage in meeting most requirements for managing an open abdomen. IAH and ACS
remain the most significant considerations for the management of the open abdomen. IAH
and ACS are in part iatrogenic and can be minimized with the appropriate resuscitation
protocols. Complications found in patients with open abdomens may be minimized with
Vacuum pack Therapy resulting in early closure of the abdomen. Consideration for the
type of closure is based on the patient’s clinical status with the optimal result of primary
facial closure. When the fascia cannot be closed, skin over granulation tissue is preferred to
skin grafting over granulation tissue to create ventral hernia. Several techniques have been
described to repair created ventral hernias. In our work, three methods had been utilized
for final reconstruction of complex midline anterior abdominal wall defects according to
size of the defect and status of tissue bed ; (I) repair with autologous tissue to bridge the
fascial gap using components separation technique (CST), (II) prosthetic repair to bridge
fascial defects and (III) Shoelace Darn Repair.

Keywords

Abdominal Wall; Complex Abdominal wall defects

Introduction

The open abdomen is an iatrogenic disease of modern abdominal surgery. Deliberately
leaving a laparotomy wound open is now the standard of care in clinical situations that
require either planned reoperations or decompression of intra-abdominal hypertension.
Damage control surgery(1) and management of severe abdominal infection are examples
of the former (2), while leaving the abdomen open after repair of a ruptured abdominal
aortic aneurysm or for abdominal compartment syndrome are examples of the latter(3, 4).
Less commonly, partial loss of the abdominal wall (5, 6) or septic dehiscence of a laparotomy
incision prohibit immediate definitive closure and result in an open abdomen (7).

The “state of the art” in definitive abdominal closure is currently undergoing a quiet
revolution. Until recently, the two options available to surgeons were either early closure
within a week or so after the original operation, or allowing the wound to granulate (the socalled
“planned ventral hernia”) with definitive closure 6–12 months later(8, 9).

Reconstruction of complex defects of the abdominal wall is both challenging and
technically demanding for surgeons. Therefore, it is imperative that the operating surgeon
is knowledgeable of the etiologies, pertinent anatomy and proper postoperative care of
these patients. Although these defects can be attributed to a many etiologic factors, the
objectives in abdominal wall reconstruction are consistent and include the restoration of
abdominal wall integrity, protection of intra abdominal viscera and the prevention of hernia
or bulge formation while maintaining an aesthetically favorable result(7).

The aim of this work is to evaluate the outcome after different methods of reconstruction
of difficult types of abdominal wall defects.

Patients and Methods

This is a prospective study on fifty two patients in different age
groups ranging from nineteen to sixty seven years with complex
anterior abdominal wall defects, in which primary closure is
impossible, whom were managed by different techniques for closure
and reconstruction of the defect.

Inclusion criteria

All the patients subjected to the study were complaining of a
complex midline abdominal wall defect or large ventral incisional
hernia defect, necessitating special techniques for closure or repair.

Patients were divided according to their presentation into two
groups:

Methods

General preoperative assessment: Surgical planning for
complex abdominal wall defects starts with a standard preoperative
evaluation. Most patients with complex abdominal wall defects had a
complex past medical histories that directly influence reconstructive
options. Cardiac and pulmonary compromise can represent a
significant associated risk during these surgeries. The risk of surgery
is related not only to the reconstruction, but also to the hernia
take down. It is hard to determine which aspect of the operation
represents the greatest risk, but it is best to think of the risk in terms
of the entirety of the case.

The preoperative evaluation included complete history, physical,
general medical evaluation, basic laboratory work and other
diagnostic or radiologic studies. The medication list was also carefully
reviewed. Most patients with complex abdominal wall defects benefit
from a CT scan of the abdomen with contrast to evaluate the extent of
the defect, the anatomy and associated pathology (as infected mesh,
abscess pockets and the extent of local inflammation and bowel
adhesions). The CT scan also was used to evaluate the extent of loss
of intra-abdominal domain.

Patients with evidence of pulmonary or cardiac compromise
underwent preoperative pulmonary function tests and full cardiac
evaluation, such as echocardiogram or cardiac stress test.

Management of the open abdomen (type I defects):
Management had been based on the physiologic status of the
patient. Recognizing the importance of long-term protection of the
abdominal contents with the patient’s physiologic status as the
main determinant, we had used Vacuum- Assisted Closure (V.A.C.)
Technique for primary closure after the initial surgery.

Patients that had been stable could have a primary closure
(early primary closure within three days was done in five cases, in
addition to two died cases, and delayed primary closure within seven
to ten days was done in ten cases in addition to four died cases). In
the remaining thirteen patients who remained unstable, creation of
ventral hernia with remote secondary repair had been utilized where
vacuum pack therapy had been continued and was changed every
48 hours. The abdominal wall had been allowed to granulate until
the skin was closed over the granulation tissue or a skin graft was
to be immediately placed directly over the granulating abdominal
contents. After wound closure, these patients were discharged when
medically stable.

Regardless of the initial cause, the acute recovery period was
managed by temporary abdominal wall closure with interposition
mesh, followed by split-thickness skin grafting once granulation of
the wound bed had occurred. Following stabilization of the patient
and resolution of the inflammatory process, the skin graft can be
removed from the wound bed, and definitive closure of the abdominal
wall could be achieved using the components separation technique.
Time to definitive closure of the abdominal wall varied from as little
as 6 months to well over 2 years from the time of initial injury.

Vacuum pack closure technique: Vacuum pack had been tried
in open defect cases especially those associated with massive trauma
and subsequent tissue loss or with severe sepsis.

First, the omentum, if present, has been used to cover the small
bowel and should be spread caudally and laterally to act as an
abdominal apron.

Next, an absorptive layer (surgical sterile towel 38 × 62 cm.
or the polyurethane sponge of a commercially available vacuumassisted
wound management system) has been encased in an
adhesive polyethylene plastic dressing (90 × 85 cm loban™ (Figure
1). This plastic-encased towel has been placed over the intestines and
tucked under the fascial edges in a 360° fashion. It has been sized
appropriately so as to not draw out from the edges of the abdominal
wall and allow for evisceration (Figure 2).

Figure 1

Sterile towel is covered on one side with adhesive plastic dressing (Ioban)

Figure 2

The towel is placed over the intestines and tucked under the fascial edges

Large bore, closed suction drains have been placed in the inferior
or caudal end of the wound above the plastic encased towel in the
deep subcutaneous gutters and brought out superiorly through long
subcutaneous tunnels (10 cm) with exit sites over the lower chest
(Figure 3). These subcutaneous tunnels have been important as they
allow the next and outer layer of adhesive plastic to seal the wound.
Drains resting on the skin allow air leaks once negative pressure is
created and therefore the vacuum necessary for wound and intraabdominal
fluid removal is not created.

Figure 3

Closed suction drains are placed above the towel, in the subcutaneous gutters, and brought out superiorly through long, subcutaneous tunnels

The abdominal closure has been completed with the placement
of a second large loban™ sheet over the entire open abdomen
(Figure 4). To ensure that the loban™ sticks securely to the skin, all
abdominal wall hair, especially in the groin and suprapubic areas, has
been shaved to promote adhesion.

Figure 4

A second, large adhesive drape is placed over the entire abdomen

Once the outer adhesive plastic is completely fixed to the
abdominal skin, the drains have been placed to low continuous
suction to create a vacuum effect, seal the wound, and remove excess
fluid and blood (Figure 5).

Figure 5

The drains are placed to low continuous suction, creating a vacuum effect; the wound is sealed.

It is important to protect the bowel from the negative pressure.
A three-layered technique was used; the inner layer that faced the
viscera consisted of a fenestrated inert sheet (IV bag or ISO 1010
Drape) covering the entire viscera to the bilateral paracolic gutters to
prevent adhesions of viscera to the overlying peritoneum. The middle
layer was made of Kerlex, lap sponges, gauze, or blue towels designed
to provide the suction media for the NPA. It is imperative that the
middle layer does not contact the underlying viscera, as it would increase the risk of fistula formation. Drains were placed in this layer
to apply the negative pressure.

The outer layer consisted of a bio-occlusive adhesive sheet
(Ioban) that was secured laterally to the flank skin and provided
enough integrity to the abdominal wall.

Methods used in definitive repair of abdominal wall defects
in created ventral hernia in open cases and in closed defects: The
determination of when to perform the definitive abdominal closure
is crucial. The reconstruction is undertaken when the skin graft can
be lifted from the underlying viscera without evidence of adhesions.
Three procedures had been used in our series including:

Component Separation technique (in eight cases)

Shoelace Darn Repair (in ten cases)

Polypropylene mesh Repair (in thirteen cases)

All patients received general anaesthesia for definitive repair
of their abdominal wall defect. Prophylactic intravenous antibiotics
were administered and prophylaxis for venous thrombosis with
sequential compression devices was instituted.

Abdominal wall components separation

Preoperative assessment: A careful history and physical
examination are critical to ascertain what components of the anterior
abdominal wall remain undisturbed from prior surgical procedures,
tumors, infection or trauma. If the clinical examination cannot
identify an intact rectus abdominis muscle and fascia, CT scan, or
magnetic resonance imaging can be useful for identifying remaining
anatomic structures.

This technique had been used in present work for repairing large
midline defects less than 20 cm in diameter. Exclusion criteria for a
rectus abdominis muscle advancement flap include:

Operative steps (10)

The first surgical step is to remove skin graft or the skin and
subcutaneous tissues from the underlying fascia, extending from
the costal margin cephalad to the pubis caudally, and to the anterior
axillary line and iliac crest laterally (Figures 6 and 7a). Skin flaps
are raised to expose the rectus and external oblique junction. Blunt
dissection along the semilunar line was then carried out in a caudad
direction. This dissection was done to preserve the periumbilical
perforators from the rectus muscle to the skin, as well as decrease the
amount of skin undermining, thereby minimizing seroma formation.

Figure 6

Component separation technique, skin flap dissection

The viscera are freed from the abdominal wall to allow the
abdominal wall to be mobilized medially. This may include extensive
enterolysis and/or reversal of skin level ostomy.

An incision is made in the external oblique aponeurosis 2 cm
lateral to the semilunar line and extending from the costal margin to
the inguinal ligament (Figure 7b).

The external oblique muscle is bluntly dissected from the
underlying internal oblique muscle (Figure 7c). Meticulous care is
taken not to disrupt the internal oblique muscle and the neurovascular
supply. This should result in approximately 5 cm of advancement in
the upper third of the abdomen, 10 cm in the mid-abdomen, and 3 cm
in the lower third of the abdomen.

Figure 7

Component separation technique, plane of dissection

If there is insufficient advancement of the musculofascial flap to
the midline, the rectus muscle may be dissected free of its posterior
sheath (Figure 8). This secondary release should produce an
additional 2-4 cm of flap advancement. Thus, in the middle third
of the abdomen, a total of 20 cm of advancement is often possible
(Figure 9).

Figure 8

Component separation technique, rectus muscle elevation; When additional advancement is needed while
performing the technique, the muscle can be elevated from the posterior sheath in its entirety.

Figure 9

The abdominal wall defect is repaired using the component separation technique

Debridement until viable fascial edges with bleeding rectus
muscle was carried out. The fascia was then closed recreating the
midline. Closed suction drains were left at each semilunar line and
also in the midline.

Excess skin was then excised allowing primary skin closure. No
special effort was made to preserve the umbilicus. Drains are almost
universally employed in an effort to prevent seromas that can occur
beneath the skin flaps and adjacent to prosthetic material if used.

The patients were mobilized on postoperative day 1 and dietary
intake was advanced as tolerated. The patient was deemed ready for
discharge when normal bowel function and adequate pain control
were present.

Prosthetic Repair; Retro Rectus Approach (11)

The essential steps are as follows:

Under general anesthesia, the old scar is excised and the hernia
sac dissected free down to the myoaponeurotic edges of the
hernial opening

The sac is then opened and its contents inspected

All adherent loops of bowel are freed and returned to the
peritoneal cavity

The excess sac is excised and the peritoneum and sac are closed
with a running absorbable synthetic suture; where there is
insufficient peritoneum to close the sac, the omentum is sutured
to the edges of the residual defect so that the prosthetic non
absorbable mesh for the actual repair will not come in contact
with bowel for fear of adhesions, sepsis, and fistula

The bed for the permanent prosthesis is prepared by slitting
open the medial edge of each rectus sheath along the hernial
defect and for 8 to 10 cm above and below it, and

The rectus muscles are separated from the posterior rectus
sheaths up to the whole length of the lateral edge of the sheath.

A sheet of propylene mesh is cut longer than the length of the
defect and wide enough to stretch from one lateral edge of the rectus
sheath to the other. This sheet then is fixed under slight tension with
a few non absorbable monofilament synthetic sutures. Thus, it will
lay on the closed peritoneum and posterior rectus sheaths and will
stretch above and below the defect and also from one lateral edge
of the rectus sheath to the other, and in the plane behind the rectus
muscles. The sutures are passed through the edge of the mesh and
then along the line of the lateral edges of the rectus sheath (linear
semilunaris), from inside the sheath, through the whole thickness
of the abdominal wall and out through stab holes in the skin, using
an Aneurysm needle (Figure 10). Each limb of the suture is passed
through the abdominal wall separately but through the same stab
wound. In some patients, when the abdominal wall is not too fatty,
a stitch with a straight needle may be passed through the abdominal
wall from the skin to the retro muscular space (Figure 11).

Figure 10

Figure 11

Rives-Stoppa technique. Both ends of the transfixing
suture are brought through the abdominal wall through separate
musculofascial incisions but the same skin incision.

The passage of each end of the suture through the muscle must be
separated by at least 1.5 cm. If they are closer, the muscle fibers may
be cut by the knot.

The sutures are tied so that the knots come to lie on the outer
surface of the external oblique muscle and each stab wound is closed
with a suture.

The upper and lower edges of the mesh are sutured in a similar
fashion. When the hernia defect reaches the upper part of the
abdominal wall, the upper edge of the mesh is passed down to lie
under the diaphragm.

The transfixing sutures are placed clockwise along each
semilunar line (Spiegel line) and at each extremity of the laparotomy.
Usually 12 transfixing sutures are sufficient but in the patient with
a huge incisional hernia, up to 21 sutures may be used. Sutures are
tied on one side and then the other side of the defect. Tailoring of
the prosthesis is important so that sutures result in some tension of
the prosthesis to re-establish the lateral muscle function that was lost
because of their midline detachment.

In the lower abdomen, below the arcuate line of Douglas, the graft
comes to lie in the pre-peritoneal plane and should be long enough
to hang into the pelvis in the retropubic space of Retzius and in the
spaces of Bogros.

In this case, it should be fixed with a few sutures to the back of
the pubis and along the pectineal lines. Two vacuum drains are laid
on the graft and brought out through separate stab wounds. The
two anterior rectus sheaths then are sutured together along their
cut medial edges with a continuous synthetic absorbable or nonabsorbable
monofilament suture. The excess skin is excised and the
wound is closed.

Postoperative care: Respiratory physiotherapy is resumed
as soon as possible after surgery. Aspiration drains are monitored
and usually removed on the third or fourth postoperative day. Antithrombo-embolism
therapy must be used.

Technique of Shoelace Darn Repair (12): A vertical elliptic
incision is used, excising the old scar. In obese patients with a
large apron of fat hanging below the pubis, panniculectomy and
abdominoplasty are combined with repair of the hernia. In this case a
long transverse incision is used at the level of the supra-pubic crease
and is extended almost to the back, curving up at its lateral ends. The
skin and fat of the apron and of the abdominal wall are freed upward
off the musculoaponeurotic layer to well up onto the anterior chest
wall. After repair of the hernia the apron and the excess skin and fat
of the lower abdominal wall, usually up to the level of the umbilicus,
are excised. Should it become necessary, an inverted midline V of
the remaining skin and fat is excised to create a tucked in waistline
(Figure 12A).

In the usual case, the skin and fat are dissected off the sac of the
hernia, as well as off the rectus sheath on each side (Figure 12B).
The anterior rectus sheaths should be exposed sufficiently to allow
for splitting off of the medial ribbon, as well as for suturing the
second layer. Time need not be wasted on accurate delineation of
the medial edge of the rectus sheaths or on leaving an absolutely
clean surface on the hernial sac. With the first continuous suture for
construction of the new midline, the sac, together with the adherent
bits of scar tissue and even old sutures that cannot be easily removed,
are returned to the abdominal cavity.

Figure 12

Shoelace Darn Repair
A. Incision and area of skin excised for panniculectomy and
abdominoplasty.
B. The skin and fat dissected off the sac and off the rectus sheath.

The new linea alba is now constructed, using a vertical strip 1 to
1.5 cm wide split off the medial edge of each anterior rectus sheath
as follows:

the abdominal wall around the hernial opening is defined,

an incision is made in each anterior rectus sheath about 1 cm
or more from its medial edge to confirm the presence of rectus
muscle

the incision is extended up and down the entire length of the
hernial opening and for about 2 cm beyond, keeping the ends
of the incision away from and parallel to the midline, above and
below the hernia (Figure 13), and

the two strips are sewn together from above downward by a
continuous over-and-over suture of 0 (metric 3.5) monofilament
Polypropylene, starting at the top corners of the incision and
incorporating the whole width of each strip (Figure 14A)

Figure 13

This not only creates the new linea alba but also returns the
unopened sac and its contents to the abdominal cavity (Figure
14B). The sac remains unopened throughout the operation. If it is
opened inadvertently, it is closed with a synthetic absorbable suture.
There is no need to open the sac and become involved in the tedious
dissection for freeing the masses of adherent bowel from the sac
walls and from each other unless dealing with an emergency case of
strangulation and bowel obstruction or with a patient with a recent
history of bowel obstruction.

In this way the posterior rectus sheaths and the rectus muscles
have been approximated at the midline. The rectus muscles have
been stretched wide and thinned, with their fibers running in many
different directions.

Sometimes an alarming gap remains between the lateral cut
edges of the rectus sheaths. This gap is closed by the second suture,
for which a 6-m 0 or 1 length of heavy monofilament Polypropylene
is used, doubled to form a loop 3 m long. The usual suture begins
at the top end of the incision in the rectus sheaths from inside the
sheath and passes out on that side, returning inside through the
opposite corner and slipping through the loop. The flat muscles
are now restored to their former lengths, and the recti muscles are
restored to their normal thickness and position by the continuous
heavy monofilament nylon suture passing to and fro in front of the
rectus abdominis muscles, between the cut edges of the anterior
rectus sheaths, and through the strong new midline anchor for the
whole length of the hernia, in the manner of a shoelace tightening a
boot (Figure 14C). Each bite on the rectus sheath passes vertically
from above down, from outside in, and from inside out at least 2 cm
from the edge, so that it crosses and pulls on the fibers of the rectus
sheath at a right angle, thereby preventing the sutures from cutting
out (Figure 15A).

Figure 14

A. The first suture line constructing the new linea alba and also
returning the sac and its contents to the abdominal cavity.
B. The large gap between the cut edges of the anterior rectus
sheaths after completion of the first suture line.
C. The continuous heavy Polypropylene shoelace suture passing
in front of the rectus abdominis muscles, between the cut edges of
the anterior rectus sheaths and through the new midline.

The sutures should be approximately 0.5 cm apart and fairly
tense to narrow the gap considerably between the cut edges of the
rectus sheaths.

Good anesthesia with relaxation is important at this stage. Each
suture is fixed at its midpoint by passing through the new mid-line,
thus preventing bow-stringing and reherniation between the sutures.
Polypropylene is tied at the bottom end of the repair. The cut edges of
the rectus sheaths have been brought parallel to each other (Figure
15B) and rectus muscles are brought at the mid-line in their normal
anatomic positions, with their fibers running parallel to each other.
With narrow or moderately wide hernias the edges of the anterior
rectus sheaths may be approximated by this suture line. In the usual
case of a large hernia, a gap of at least a few centimeters remains,
with the continuous pliable to-and-fro shoelace suture adjusting
itself to the differing widths and tension across the fascial defect and
thus functionally substituting for the missing anterior rectus sheaths
(Figure 15C and D). Excess skin and fat are excised.

Figure 15

A vacuum drain is placed on either side, and each is brought out
through a separate stab. The incision is closed with automatic staples
or a continuous suture of fine monofilament polyamide thread.

Postoperative outpatient follow up: All discharged patients
were monitored frequently (approximately once weekly) until full
healing occurred. Additional visits every two months.

Patients were followed up by clinical examination in both supine
and erect positions for the previous lesion or any new lesions.

Radiographic examination by computed tomography was
requested only when recurrence was in question.

Statistical analysis

The collected data were tabulated and analyzed by SPSS
(statistical package for the social science software) statistical package
version 13 on IBM compatible computer.

Quantitative data were expressed as means and standard
deviation (X + SD) and analyzed by applying mann Whitney U test for
the not normally distrusted variables.

Qualitative data were expressed as number and percentage (No.
and %) and analyzed by applying chi-square (X2) test and ANOVA (f)
test.

Same letter means no significance difference. Different letters
mean significant difference. All these tests were used as tests of
significance at P < 0.05.

Results

Our patients were 28 (53.8%) males and 24 (46.2%) females
with age ranging from 19 to 67 with mean ±SD = 36.1 + 12.85 in cases
with complete defects and 37.9 + 13.3 in those with partial defects.
Also, males dominated in the first group with complete fascial defect
(58.8%) while females were dominant the second group with partial
defect (55.6%), with no statistically significant difference between
the two groups regarding either gender or age of patients (Table 1).

Abdominal trauma with resultant abdominal wall tissue loss
was the most common etiology of complete abdominal wall defect,
in twelve out of thirty four patients (35.3%), followed by wound
dehiscence following abdominal operations (29.4%), infection of
recent laparotomies (26.5) and after abdominal wall desmoid tumor
excision in one case (2.9%), while other cases were presented during
the course of preparation for a second exploration in emergency
situations (5.9%), there is a statistically significant difference, as
shown in (Table 2).

In thirty four of our cases, it was impossible to primarily close
the abdomen, thus a temporal closure was indicated. In 26% of cases,
burst of the abdomen was the indication of temporal closure, while
in 20% of cases; abdominal compartmental syndrome (ACS) was
the indication. Also in emergency situations, damage control with
relaparotomy was responsible for 15% of cases of temporal closure.
Other indications of temporal closure were severe intra abdominal
sepsis (11.8%), debridement of necrosis (8.8%), necrotizing fasciitis
(5.9%) and lastly, excision of an abdominal wall tumor in (2.9%),
with statistically significant difference as shown in (Table 3).

Indications of temporal closure

No.

%

Intra-abdominal sepsis due to anastomotic disruption

3

8.8%

Abdominal compartmental syndrome (ACS)

7

20.6%

Damage control relaparotomy

5

14.7%

Intra-abdominal sepsis due to contamination

4

11.8%

Necrotizing fasciitis

2

5.9%

Debridement of necrosis

3

8.8%

Burst abdomen

9

26.5%

Abdominal wall tumor

1

2.9%

Total

34

100%

Table 3:Indications of temporal closure

The time period consumed for temporal closure ranged from one
day in emergency cases up to fifty seven days in cases with severe
sepsis, intestinal fistula or necrotizing fasciitis and this had resulted
in long hospital stay in such cases, with mean equals 19.15 and
stander deviation of 11.33 as in Table (4).

Duration of Temporal closure (days)

Mean ± std Deviation

19.15±11.33

Range

1-57

Table 4:Duration of Temporal closure (days) in “Open Abdomen”

In those presented with open fascial defect, out of twenty eight
patients subjected to temporal vacuum assisted closure (VAC) as
a bridge therapy for definitive closure, early primary closure was
possible in only five patients (17.9%), in addition to two died cases,
delayed primary closure could be done in another ten cases (35.7%),
in addition to four died cases, while in the remaining thirteen cases
(46.4%), creation of ventral hernia with secondary repair was done
without any mortality and this is clear in (Figure 16).

Figure 27

The time allowed for wounds to granulate ranged from fourteen
to forty nine days with mean 19.90 and stander deviation 8.93, after
granulation tissue formation we could do skin graft or flap to cover
the defect and create an incisional ventral hernia, the time spent
while creating ventral hernia ranged from one hundred sixty six
days to three hundred fifty six days with mean 239.93 and stander
deviation 60.27 (Table 5).

Mean

Std Deviation

Range

Time to granulate (days)

19.90

8.93

14-49

Time to create ventral hernia

239.93

60.27

166-356

Table 5: Time to granulate and Time to create ventral hernia (days) in late closure of “Open Abdomen”

Length as well as width of the defect was a major determinant
factor in the choice of the techniques used for closure of the defect
in cases with open abdomen, this is shown in (Table 6) as the defect
length ranged from 15 -24, 12 -21 and 11 -23 cm in those underwent
component separation technique, shoelace darn repair and propylene
mesh repair respectively, While the width ranged from 10 -20, 8 -20
and 8 -18 cm respectively in the same order with no statistically significant difference between the three techniques.

Technique of late source

Component Separation technique (No.=8)

Shoelace Darn Repair (No.=10)

Propylene mesh Repair (No.=13)

Length of the defect (cm)

Mean

19.63

16.80

17.23

Std Deviation

3.25

3.26

4.21

Range

15-24

12-21

11-23

Width of the defect (cm)

Mean

15.38

14.80

3.31

Std Deviation

3.74

4.42

3.17

Range

10-20

8-20

8-18

Table 6: Time to granulate and Time to create ventral hernia (days) in late closure of “Open Abdomen”
ANOVA. P= 0.243. 0.430. No statistically significant difference.

Table (7) shows that the mean operative Time of final closure
techniques was 161.06 ranging from 98 to 255 days and stander
deviation of 48.17, it is also clear that the mean of the volume of blood
loss was 232.23 ranging from 100 to 500 cc with stander deviation
of 107.43.

Operative Time of final Closure technique

Mean

161.06

Std Deviation

48.17

Range

98-255

Blood loss (CC)

Mean

232.23

Std Deviation

107.43

Range

100-500

Table 7: Operative Time and Blood loss (CC) in final closure techniques of “Open Abdomen”

Some complications had followed the final defect closure
techniques such as wound infection in the three techniques with
different percentages; 12.5% in component separation technique,
10% with shoelace darn repair and 7.7% with propylene mesh repair.
Other complications included: hematoma in10% of shoelace darn
repair and in 7.7% of propylene mesh repair; also skin necrosis had
occurred in 20% of cases with shoelace darn repair and in 7.7% of
propylene mesh repair cases while mesh infection was seen in 7.7%
of propylene mesh repair cases (Table 8).

Length of hospital stay was nearly equal in the three modalities;
in component separation it ranged from thirty seven to sixty seven
days with mean 48.25 and standard deviation 11.07, in shoelace darn repair hospital stay ranged from thirty three to sixty six days with
mean 45.20 and standard deviation 10.87, while in propylene mesh
repair hospital stay ranged from twenty one to sixty seven days with
mean 41.23 and standard deviation 12.91 (Table 9).

Technique of late closure

Component Separation technique (No.=8)

Shoelace Darn Repair (No.=10)

Propylene mesh Repair (No.=13)

HospitalStay (days)

Mean

48.25

45.

41.23

Std Deviation

11.07

10.87

12.91

Range

37-67

33-66

21-67

Table 9: Hospital Stay in ventral hernia and in late closure of open Abdomen
ANOVA, P=0.413. No statistically significant difference.

Recurrence rate was found to be low in those who underwent
component separation technique (12.5%), Highest in shoelace darn
repair (30.0%) with an intermediate incidence in patients with
propylene mesh repair (23.1%) but with no significant statistical
difference, and the time of recurrence is included in (Table 10).

Component Separation technique (No.=8)

Shoelace Darn Repair (No.=10)

Propylene mesh Repair (No.=13)

Recurrence

1 (12.5%)

3 (30.0%)

3 (23.1%)

Recurrence Time (mouths)

10

6. 7. 11

9. 10. 12

Table 10: Recurrence in 31 patients after ventral hernia repair and after late closure of open Abdomen
Kruskal-Wallis Test. P = 0.676. No statistically significant difference

All mortalities had occurred within cases presented to us with
an open defect with no single case died among cases with covered
defects or ventral hernias; this indicates that the cause of death was
due to the associated original pathology rather than the defect itself
or its repair, the mortality rate was (11.5%) with two cases died due
to trauma, two cases died due to infection of recent laparotomy, one
case died due to acute dehiscence and one case died during planning
for relaparotomy as shown in (Table 11).

Clinical Data of mortality

No.

%

Cause of complete facial defect

Abdominal trauma

2

33.3%

Acute dehiscence

1

16.7%

Planned re-exploration

1

16.7%

Infection of recent laparotomy

2

33.3%

Indications of temporal

ACS CS

1

16.7%

Intra abdominal sepsis due to contamination

1

16.7%

Underlying primary operation in complete defect

Repair of Traumatic perforation of colon

1

16.7%

Resection-anastomosis for gangrenous loop

2

33.3%

Necrotizing pancreatitis

1

16.7%

penetrating trauma with Intraperitoneal hemorrhage

1

16.7%

Blunt trauma with liver injury

1

16.7%

Table 11: Clinical Data of mortality cases

Discussion

The present work focuses on midline abdominal wall defects
that cannot be closed primarily, often resulting from intra-abdominal
catastrophes, or recurrent incisional hernias. In these patients, a large fascial gap results from retraction of the rectus abdominis
muscle prohibiting tension free primary closure of the fascia. In
a considerable part of patients, these defects are accompanied by
contamination or infection.

The open abdomen is becoming an increasingly common
challenging problem for the general surgeon to manage. The OA
is a planned surgical technique for managing damage control
(DC) trauma patients, severe abdominal sepsis, intra abdominal
hypertension (IAH), necrotizing infections of the abdominal wall
and acute mesenteric ischemia (13), we agree with this statement as
these were the etiologies in our patients in addition to abdominanal
wall tumours as desmoids tumour. It is a temporizing measure
that allows a planned escape from the operating theater to control
medical bleeding, correct metabolic derangements and hypothermia
or facilitate repeated abdominal debridement or bowel resections.

Prolonged laparotomy in critically ill trauma victims has a high
mortality, principally by worsening the synergistic effects of the
vicious triad of trauma; hypothermia, acidosis and coagulopathy (14).

In an effort to reduce this mortality, Rotondo et al.(15) introduced
the concept of damage control surgery (DCS); an abbreviated laparotomy
to control hemorrhage and limit contamination and placement of the
patient on the intensive care unit for aggressive restoration of normal
physiology before a second laparotomy 24 - 48 hours later. In this
situation temporary abdominal closure is quick to apply and remove,
limits heat and fluid losses and simplifies nursing care, we successfully
used this technique in our study in open abdomen cases.

Laboratory values including; a base deficit < -6 in patients < 55
years of age or < -15 in patients > 55 years of age, lactate > 5 mmol/L,
prothrombin time > 16, or partial thromboplastin time > 50 have
been associated with the need for DCS and decreased survival(16).

Any of these factors in a trauma patient undergoing open
laparotomy should prompt the surgeon to perform an abbreviated
first procedure and use TAC.

In the present study, damage control techniques have been
utilized in 12 trauma patients, 7 due to ACS, 5 patients requiring rapid
abbreviated and planned resuscitation due to liver laceration with
pack to control bleeding, lacerated cecum and transected duodenum
with coagulopathy, hypothermia and metabolic acidosis.

Damage control techniques and use of the OA may also be utilized
in other populations; patients with abdominal compartment (ACS)
syndrome, defined as sustained intra abdominal pressure > 20 mmHg
with the onset of new organ dysfunction, both occur as a sequel of
a rapid rise in intra abdominal pressure against a closed abdominal
wall decreasing visceral blood flow. ACS may develop following an
intra abdominal surgical procedure (primary ACS) or following third
space accumulation secondary to aggressive resuscitation (secondary
ACS) in conditions such as pancreatitis and burns (17).

ACS should be managed with decompressive laparotomy and
creation of an OA. Treatment requires early recognition of intra
abdominal hypertension followed by decompression before the onset
of Multi Organ Dysfunction Syndrome (MODS) (18).

Patients with acutely increased intra abdominal pressures > 25
mmHg without acute organ dysfunction should also be considered for
prophylactic decompressive laparotomy. Lastly, patients at high risk
for postoperative ACS should be left open prophylactically following
completion of surgery. These patients include those requiring > 15
L of crystalloid, or 10 units of PRBC intra operatively or patients
with increased peak inspiratory pressures > 40 mmHg upon fascial
closure (17).

The OA is also used in the management of ‘‘second-look’’ or
staged laparotomy, which may occur after an embolic phenomenon or
mesenteric venous occlusive disease. It is also employed in patients
with severe abdominal sepsis necessitating repeated debridement,
most specifically severe pancreatic necrosis. In our thesis, large
contaminated abdominal wall defects occurred after infection of
recent laparotomy wounds in 9 patients.

There appear to be two groups of patients with OA; the first
group is relatively uncomplicated and can be closed within 4–7
days, these patients generally have a high rate of primary fascial
closure and likely do well regardless of the choice of TAC (19). In our
study, five out of the thirty four open defect cases are present in this
group. The second group, for many reasons, has more complicated
and prolonged resuscitative efforts and hospital courses, the timing
of abdominal closure in this group tends to extend beyond 7 days,
generally to 20–40 days (20). In our study, ten cases belong to that group. The rates of primary closure are much lower in these patients,
and the type of TAC chosen may have a significant impact on their
ability to achieve primary facial closure. Several risk factors have
been found that predict a more prolonged or complicated course—
and subsequently a diminished rate of primary closure; prolonged
duration of OA, multisystem injuries, particularly colonic or duodenal
and active infection(21).

In our patients, regardless of the initial cause, the acute recovery
period were managed by temporary abdominal wall closure.

Unfortunately none of the techniques described so far controls
the release of the often large volumes of exudate that are liberated
from the partially exposed edematous bowel. In order to address this
worry, wall suction was utilized to extract the fluid from beneath a
temporary abdominal closure; so called ‘Vacuum pack’ therapy. The
application of negative pressure was also postulated to increase
closure rates. Barker et al reported a series of 112 patients treated in
this manner over a 7 year period with a 55% primary fascial closure
rate, although if the patients who died before abdominal closure was
attempted are excluded this would rise to 69%(22).

In our study, we agree with this as the rate of primary closure
(either early or late) is 44% but if we exclude the mortalities from
calculation, the rate will rise to 53%. Delays beyond 6 days from
injury were however associated with a much lower chance of success
of primary closure because of fascial retraction and adherence of the
viscera to the abdominal wall.

Quyn et al. (23) suggested that VAC induces some degree of
tissue stretching, a stimulus to increased proliferation, angiogenesis
and promotion of matrix synthesis. Vacuum-assisted closure is an
evolution of the ‘do-it-yourself’ vacuum dressings that utilizes subatmospheric
pressure to manage a variety of acute and chronic
wounds including the open abdomen.

A purpose made fenestrated non adherent sheet is placed
over the abdominal cavity to retain the contents and prevent their
adhesion to the abdominal wall. The defect between the two fascial
edges of the abdominal wall is then filled with a foam sponge cut by
the surgeon to fit precisely. The whole abdomen is then covered by
an adhesive drape for at least 5cm beyond the wound edges and the
end of a length of suction tubing is embedded in the sponge through
a small cut in the top drape.

Intermittent suction increases the amount of granulation tissue
in a healing wound by 13% compared to continuous suction. The
majority of the evidence for VAC therapy comes from small non randomized trials, animal studies or experimental data relating
to VAC for chronic wound management, although some of the
advantages may also be applicable to open abdominal wounds.

The overwhelming aim of VAC therapy however is to improve
management of the open abdomen to decrease the rate of planned
ventral hernia, requiring subsequent reconstructive surgery, by
maximizing the rate of delayed primary fascial closure.

In the present series, out of 34 patients treated with VAC, 15 had
primary closure (44%); 5 within 3 days and 10 within 17 days, with
a mortality of 17%. Quyn et al. (23) reported similar results. The
highest delayed primary closure rates were seen with the Wittmann
patch and VAC.

This three-layered vacuum pack was able to maintain visceral
containment, prevent desiccation and allow continuous evacuation
of peritoneal fluids. The authors achieved primary fascial closure in
68% of patients with a 5% incidence of fistula formation (19).

Boele van Hensbroek et al. (24) have reported success using
similar systems with primary fascial closure rates ranging from 35%
to 92% (usually > 50%). Fistula rates ranged from 0% to 15% with
an average of 5.7%.

In our series, the rate of fistula was two cases (15.3%) which
is much more lell than these, this difference may be explained by a
difference in the nature of cases and the method and place of case
collection.

The principle worry when using VAC over exposed bowel is one
of entero-cutaneous fistula, especially if there are exposed intestinal
anastomoses, given that fistula in these circumstances rarely heal
with conservative management compared to 80% healing rates seen
when the abdominal wall is intact(23, 25).

This complication has been reported in most series reporting
treatment of the open abdomen. The bowel is vulnerable during
dressing changes and further surgery, edema, adhesions, ischemia
and malnutrition increase the risk of injury (26).

Miller et al. (20) reported only a single fistula in 53 successive
patients (1.88%) treated with the commercial VAC system. Where
as in present work, the fistulation occurred in 2 out of 34 patients
(5.9%) with VAC.

Teixeira et al. (21) suggested that the risk of fistula is increased
with intra abdominal sepsis and anastomoses directly underneath
the vacuum pack, particularly colonic or duodenal ones. Fistula rates
were also increased by an increased duration of OA and in patients in
whom primary closure was not possible.

In vacuum pack “sandwich” technique, the visceral sac is first
wrapped by a polyethylene sheet which is tucked between the
bowel and the abdominal wall to be a physical barrier that prevents
adhesion formation between the bowel and the abdominal wall. In
other words, it preserves the peritoneal space and greatly delays the
onset of “frozen abdomen”.

Many patients were treated with the VAC device up to 14 days,
and at that time, skin grafts were placed on granulated mesh or
bowel. As the authors have gained experience, VAC times longer
than 14 days have allowed primary closure of abdominal wounds
previously thought un closable during the same hospital stay. Time
to definitive closure of all layers of the abdomen without a hernia
was, therefore, dramatically reduced and a second delayed closure
procedure was avoided.

Towel clips and sutures can tear soft tissue or fascia and
damage the tissue needed for final abdominal wall closure. When
used in combination or in sequence with traditional reconstructive
procedures, therapy with VAC has provided early quality closures
of the abdominal wall. Large defects associated with a great deal of
inflammation or contamination can be shrunk with the use of VAC (27).

Following stabilization of the patient and resolution of the
inflammatory process, 13 of 34 patients with open abdomen, in
present work, failed to be closed primarily due to several causes;
entero cutaneous fistula in two patients, persistent abdominal sepsis
in one patient, need of debridement in one patient and large fascial
defect in nine patients.

In the presence of sepsis or multiple organ dys function, the
patient typically continues to accumulate fluid and interstitial edema,
a process that may take weeks to resolve. Lateral retraction of the
wound edges results in a progressively larger gap in the fascia (9).

From the perspective of abdominal closure, the granulation
process obliterates the peritoneal space between the abdominal wall
and the abdominal visceral mass, so that the abdominal contents get
adherent to the undersurface of the anterior abdominal wall. If the
abdomen cannot be closed by the end of the first week, granulation
tissue starts to develop, and a “frozen abdomen” is evident by the
end of the second week, this creates a hostile environment for early
fascial closure and thus necessitates secondary staged fascial closure
methods (28).

This “frozen abdomen” precludes definitive abdominal closure
because it is impossible to mobilize the abdominal wall off the
adherent bowel loops (29).

The granulating wound is thus covered with a skin graft and
allowed to undergo gradual contraction and maturation over several
months, the so-called “planned ventral hernia”, a concept first
introduced by Fabian et al as a safe strategy for managing the open
abdomen(9).

Our policy for the management of these patients, based on recent
advances in literature, had been to continue with vacuum pack which
is to be changed every 48 hours, allowing granulation tissue to
cover intestine followed by Split-thickness skin graft applied when
granulation tissue was adequate. Skin graft can be removed later
from the wound bed and definitive closure of the abdominal wall can
be achieved.

Initial skin graft closure of open abdominal wounds in patients
with a frozen abdomen is advantageous for several reasons; it allows
wound control and a return to normal homeostasis and in patients
with fistula, skin grafting improves comfort allowing application of
an ostomy appliance, in addition, skin grafts have a low morbidity.
Once control of the abdominal cavity and wound is accomplished,
attention can be directed towards a delayed definitive closure of the
defect. Time to definitive closure of the abdominal wall has varied
from as little as 6 months to well over 2 years from the time of initial
injury (28).

The time allowed for wounds to granulate in 13 of our patients
with open abdomen ranged from fourteen to forty nine days with a
mean of 19.90 +8.93 days and the time for creating ventral hernia
ranged from 166 – 356 days with a mean of 239.93 + 60.27 days.

As with many surgical techniques, it is not the particular
operation that has failed or has been met with success, but instead
it is the choice of procedures that is of utmost importance. No one
procedure is ideal for all situations and it is therefore incumbent upon
the surgeon to select the proper procedure to fit the particular needs
of the situation. In addressing complicated defects of the abdominal
wall, the components separation technique can be viewed as simply a
part, albeit a very important one, of the armamentarium necessary to
address these deficits based upon their location, depth of the defect,
timing of presentation, background milieu of the wound bed and
the patient himself or herself. Rohrich and colleagues, in 2000 and
Mathes and colleagues, also in 2000, had addressed this issue, each
with their own approach and algorithms. Several techniques have
been described to repair created ventral hernias (30).

In our work, three methods had been utilized for final
reconstruction of complex midline anterior abdominal wall defects;

The CST is a useful technique for large midline abdominal hernias. Proposed benefits of this procedure focus on its use of innervated
vascularized autologous tissues for reconstructing anterior
abdominal wall defects. Additionally, beyond providing a tensionless
closure, the use of these innervated myofascial flaps helps to recreate
the dynamic nature of the native abdominal wall.

Ger and Duboys (31) recognized the benefits of innervated
contractile muscle over denervated fascia or synthetic mesh, citing its
ability to better resist strain and to better redistribute tension over
the broad expanse of the abdominal wall.

Components separation is ideal for large midline myofascial
defects. Bilateral relaxing incisions and release allow for
approximately 12 cm, 22 cm and 10 cm of advancement in the upper,
middle and lower thirds of the abdomen respectively (32).

In present work, component separation technique corrected
defects 10-20 cm in width. Although the component separation
technique is an attractive method for the reconstruction of abdominal
wall defects, this method has five major disadvantages; First, the
reherniation rate is relatively high, this might be related to the rather
complex hernias which were included in the study and the 35% of
reconstructions that were done under contaminated conditions but
because no reasonable alternative for reconstruction under these
circumstances is available, the component separation technique
seems to be valuable. Second, the skin and subcutaneous tissue
must be mobilized over a large distance to reach the aponeurosis
of the external oblique muscle, which is retracted far laterally into
the flank, this creates a large wound surface that covers the whole
ventral abdominal wall from the costal margin to the pubic bone
and predisposes to hematoma or seroma formation and infection.
Also, mobilization of the skin and subcutaneous tissue endangers its
blood supply, which can lead to skin necrosis in the midline. If the
musculocutanous perforators of the epigastric artery are transected,
the blood supply of the skin depends solely on the intercostal arteries.

Interference with the blood supply from the intercostal arteries
by scars, enterostomies, or even drains can result in skin necrosis, as
was found in 20% of the patients in the study by Lowe and colleagues
in 2000, here in our study the skin necrosis had occurred in 12.5%
of those undergoing CST. Third, the technique de-stabilizes the outer
layer of the abdominal wall, allowing shifting of the skin in relation
to the underlying myoaponeurotic tissue, this makes application in
patients with enterostomies difficult. Under these circumstances, we
now use a modified technique in which separate incisions are made
just lateral to the rectus sheath for transection of the aponeurosis
of the external oblique muscle, in this way, the wound surface is
markedly reduced and the blood supply to the skin via the dominant
musculocutaneous perforators of the epigastric artery is preserved.
A well vascularized compound flap is created that can be advanced
to the midline. Existing enterostomies can be left in place and new
enterostomies are facilitated because shifting of the skin in relation
to the rectus muscle has been prevented (33).

Wound complications are reported in about a quarter of patients,
this is explained by the very large wound surface, averaging 700
cm2, which is created by mobilizing the skin and the subcutaneous
fascia from the ventral abdominal wall muscles, in combination with
transection of the peri umbilical epigastric perforating arteries,
thus compromising the blood supply of the skin. Transection of
the external oblique muscle and mobilization from the underlying
internal oblique muscle further enlarges the wound surface and
these very large wounds are predisposed to seroma and hematoma
formation, also skin necrosis may occur because the blood supply to
the ventral abdominal skin is insuficient especially when the blood
supply via the intercostal, superficial circumfex iliac and external
pudendal arteries is compromised owing to previous transverse or
subcostal incisions(34).

Seroma and hematoma formation and the compromised blood
supply of the skin in concert with long operations, sometimes performed
in a contaminated field, predispose to the development of wound
infections and these were found in about 20% of patients (35).

Because all but one of the series are retrospective and the method
of wound surveillance and follow up are mentioned in only three
studies, the overall complication rate is probably underestimated (35).

It is remarkable that after CST, which is frequently complicated
by wound healing disturbances, reherniation rates of less than 10%
have been reported.

In the study by de Vries Reilingh et al.(36), which exhibited the
highest rate of recurrence (32%), midline fascial closure was achieved
using an absorbable running suture of polydioxanone (PDS-loop).

Prosthetics require reliable skin and subcutaneous coverage and
an adequate wound bed. The main problem with mesh material is
that it provides no dynamic support to the abdominal wall. Problems
occur at the interface between the dynamic native abdominal tissues
and the static prosthetic mesh material. Fistula formation and
infection are potential complications, but in most series are below
3%. Attempts should be made to interpose omentum between bowel
and mesh to avoid adhesions.

The ideal prosthetic material for abdominal wall repair is
not available. In very large hernias, where the peritoneum and/
or the greater omentum are often lacking, dense adhesions to the
bowels or damage to the intra abdominal viscera may occur when
polypropylene is used (37).

The ideal prosthesis combines two conflicting properties:
incorporation of the mesh into the fibrocollagenous tissue for
adequate anchorage to the adjacent fascia and no adhesions to the
mesh. Moreover, prosthetic repair increases the risk of infection,
which is a major risk in patients with large hernias since wound
complications are frequent.

De Vries Reilingh et al. (35) carried out a RCT comparing CST
and prosthetic repair in patients with giant midline abdominal
wall hernias. Both procedures produced a similar high wound
complication rate; hematoma in 5%, seroma in 28%, skin necrosis
13% and wound infection in 5%. This coincides with our findings.
These complications had major consequences for patients who
underwent prosthetic repair, as the prosthesis had to be removed
owing to infection in 38%.

Reherniation, including that in patients with explanted the
prostheses, occurred in 60% after prosthetic repair and 53% after
CST, at a follow-up of 24 months.

The shoelace darn repair is superior to re-suture or synthetic
nonabsorbable mesh repair for the following reasons (38):

Quick, easy, extra-peritoneal method that simply returns the
unopened hernial sac and its contents to the abdominal cavity
and thus avoids the tedious and perhaps risky dissection of
the adherent loops of the bowel on the inner surface of the sac
required in the re-suture and in the mesh repair.

The repair restores the functional anatomy of the abdominal wall
as it reconstructs a strong new linea alba and allows the rectus
muscles to straighten and lie along side each other at the midline,
it also reconstructs the anterior rectus sheaths and fixes them to
the new linea alba.

Tension free repair.

Minimal suture material requirement.

The shoelace darn repair, in present series, had comparable
results as CST and prothetic repair as regards incidence of the
postoperative complications, hospital stay and recurrence rate.

Abrahamson and Elder (38) wrote that he has no deaths and 2%
recurrence; he concluded that since the operation is entirely extra
peritoneal and technically relatively simple and quick, it is eminently
suitable for elderly patients with other general medical problems.

Conclusion

The management of patients with open abdomens is an evolving
concept.

Certain techniques for managing the open abdomen patients can
be effective in treating ACS.

A Temporal Abdominal Closure should not only protect the intraabdominal
contents, but facilitate primary closure of the fascia
and minimize the need for secondary repairs of ventral hernias
and subsequent repair.

Serial bladder pressure monitoring should be a part of postoperative
management protocols in high-risk patients and
decompression of the abdomen with a pressure of > 25-30 mmHg
should be considered even without clear clinical evidence of ACS.

While many closure techniques are reported in the literature, a
dynamic closure technique, such as Vacuum pack appears to have
an advantage in meeting most requirements for managing an
open abdomen.

IAH and ACS remain the most significant considerations for the
management of the open abdomen.

Complications found in patients with open abdomens may be
minimized with Vacuum pack Therapy resulting in early closure
of the abdomen.

Consideration for the type of closure is based on the patient’s
clinical status with the optimal result of primary facial closure.

When the fascia cannot be closed, skin over granulation tissue
is preferred to skin grafting over granulation tissue to create
ventral hernia.

Several techniques have been described to repair created ventral
hernias.